Pediatric Tele-Critical Care: Initial Experience with a Continuous Surveillance Model Aiming to Prevent Cardiac Arrest in Children with Critical Heart Disease.

Introduction: Despite advances in treatment of children with critical heart disease, cardiac arrest (CA) remains a common occurrence. We provided virtual support to bedside teams (BTs) from a tele-critical care (TCC) unit in a pediatric cardiac intensive care unit (CICU) and focused on early detection of concerning trends (CT) and avoidance of CA. Virtual surveillance workflows included a review of remote monitoring, video feed from patient room cameras, medical records, and artificial intelligence tools. We present our initial experience with a focus on critical communications (CCs) to BTs. Methods: A retrospective, descriptive review of TCC activities was conducted from January 2019 to December 2022, involving electronic databases and electronic medical records of patients in the CICU, including related CCs to BTs, responses from BTs, and related CA. Results: We conducted 18,171 TCC activities, including 2,678 non-CCs and 248 CCs. Over time, there was a significant increase in the proportion of CCs related with CT (p = 0.002), respiratory concerns (<0.001), and abnormalities in cardiac rhythm (p = 0.04). Among a sample of 244 CCs, subsequent interventions by BTs resulted in adjustment of medical treatment (127), respiratory support (68), surgery or intervention (19), cardiac rhythm control (17), imaging study (14), early resuscitation (9), and others (10). Conclusions: CCs from a TCC unit in a pediatric CICU changed over time with an increased focus on CT and resulted in early interventions, potentially contributing to avoiding CA. This model of care in pediatric cardiac critical care has the potential to improve patient safety.

Direct-to-patient telemedicine: Expanding access to regional pediatric specialty care.

Telemedicine is seen as a useful tool in reducing gaps in health care but this technology-enabled care can also exacerbate health inequity if not implemented with a focus on inclusivity. Though many studies have reported improvements as well as exacerbation of disparities in access to care in their telehealth programs, there does not exist a common evaluation tool to assess these programs. To mitigate the impact of COVID-19 on health care workers and protect medically vulnerable children, in March 2020 we expanded our pre-established specialty and subspecialty direct-to-patient pediatric telemedicine program in a high volume urban pediatric health system. Our program aimed to prevent disparities in pediatric health care. In this study, using a "Pillars of Access" approach as a model to evaluate impact and access to care of our direct-to-patient telemedicine program, we analyzed the patients that were seen pre-COVID versus post-COVID. Our study demonstrated an increase in telemedicine visits for patients from diverse socioeconomic and racial backgrounds, and geographically underserved communities. We also observed an increase in telemedicine visits for mental health complaints and for certain categories of high-risk patients. This study was not designed to identify language and cultural barriers to telemedicine. Future identification of these specific barriers is needed. The tool to evaluate telehealth impact/access to care through a "Pillars of Access" approach presented here could serve as a model for implementation of telehealth programs. Our study highlights telemedicine programs as a mechanism to address healthcare inequity and overcome barriers to care.

Early prediction of critical events for infants with single-ventricle physiology in critical care using routinely collected data.

OBJECTIVE: Critical events are common and difficult to predict among infants with congenital heart disease and are associated with mortality and long-term sequelae. We aimed to achieve early prediction of critical events, that is, cardiopulmonary resuscitation, emergency endotracheal intubation, and extracorporeal membrane oxygenation in infants with single-ventricle physiology before second-stage surgery. We hypothesized that naïve Bayesian models learned from expert knowledge and clinical data can predict critical events early and accurately. METHODS: We collected 93 patients with single-ventricle physiology admitted to intensive care units in a single tertiary pediatric hospital between 2014 and 2017. Using knowledge elicited from experienced cardiac-intensive-care-unit providers and machine-learning techniques, we developed and evaluated the Cardiac-intensive-care Warning INdex (C-WIN) system, consisting of a set of naïve Bayesian models that leverage routinely collected data. We evaluated predictive performance using the area under the receiver operating characteristic curve, sensitivity, and specificity. We performed the evaluation at 5 different prediction horizons: 1, 2, 4, 6, and 8 hours before the onset of critical events. RESULTS: The area under the receiver operating characteristic curves of the C-WIN models ranged between 0.73 and 0.88 at different prediction horizons. At 1 hour before critical events, C-WIN was able to detect events with an area under the receiver operating characteristic curve of 0.88 (95% confidence interval, 0.84-0.92) and a sensitivity of 84% at the 81% specificity level. CONCLUSIONS: Predictive models may enhance clinicians' ability to identify infants with single-ventricle physiology at high risk of critical events. Early prediction of critical events may indicate the need to perform timely interventions, potentially reducing morbidity, mortality, and health care costs.

Telemedicine in Pediatric Critical Care: A Retrospective Study in an International Extracorporeal Membrane Oxygenation Program.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is an invaluable rescue technique for critically ill children with imminent or present cardiopulmonary collapse. However, medical team expertise to optimize results and decrease complications is scarce. Telemedicine can be used to enhance the delivery of quality interventions. MATERIALS AND METHODS: This is a retrospective review of pediatric patients assisted with ECMO in the cardiac intensive care unit (CICU) at Fundación Cardiovascular de Colombia from July 2011 to June 2015 (telemedicine) compared with similar patients from a previous period (pretelemedicine). Collected information included demographic data, cardiac diagnosis, risk adjustment for congenital heart surgery (RACHS-1), hospital mortality, CICU and hospital length of stay (LOS), ECMO type, and ECMO run hours as well as specific telemedicine information. RESULTS: Fifty-seven patients in the pretelemedicine and 109 in the telemedicine periods were included in the analysis. Forty-nine teleconsulted patients received 218 teleconsultations, with a recommendation for diagnostic or interventional catheterization in 38 patients (77.5%). A surgical procedure for significant residual lesions was recommended in 30 patients (61.2%). Patients in the telemedicine period were older (4.7 months vs. 1.6 months, p = 0.006), more likely to receive operating room ECMO (43.1% vs. 24.6%, p = 0.02), and had a higher proportion of patients with two-ventricle physiology (73.4% vs. 54.4%, p = 0.013). Hospital survival was higher during the telemedicine period (54.1% vs. 29.8%, p = 0.002), with a longer hospital LOS (67 days vs. 28 days, p < 0.001). CONCLUSION: The implementation of telemedicine-assisted interventions in a pediatric ECMO program delivered valuable diagnostic and therapeutic advice, was associated with significant changes in selection criteria and model of care, and an increased hospital survival.

Use of Therapeutic Plasma Exchange during Extracorporeal Life Support in Critically Ill Cardiac Children with Thrombocytopenia-Associated Multi-Organ Failure.

BACKGROUND: Thrombocytopenia-associated multi-organ failure (TAMOF) in children is a well-described factor for increased hospital mortality. Low cardiac output syndrome (LCOS) and the effects of cardiopulmonary bypass may manifest with several adverse physiologic and immunologic effects, with varying degrees of thrombocytopenia and multi-organ dysfunction, sometimes very similar to TAMOF. LCOS is a common occurrence in children with critical heart disease, presenting in as much as 23.8% of infants postoperative of congenital heart surgery. Therapeutic plasma exchange (TPE) has been offered as a promising therapy for TAMOF; however, the therapeutic implications of this modality in children with critical heart disease and a clinical diagnosis of TAMOF are unknown. OBJECTIVES: We describe our institutional experience with TPE as an adjuvant rescue therapy for children with critical heart disease and a clinical diagnosis of TAMOF, while supported by extracorporeal membrane oxygenation (ECMO). METHODS: Single-center retrospective analysis of children with critical heart disease admitted to the CICU and supported by ECMO, undergoing TPE for a clinical diagnosis of TAMOF between January 2006 and June 2015. RESULTS: Forty-one patients were included for analysis. Median age and weight of patients was 0.6 years (range 0.0-17.2) and 8.5 kg (range 1.5-80.0). TPE was initiated at a median of 1 day (0-13) after initiation of ECMO. Modified organ failure index (MOFI) and platelet count improved after TPE start (p < 0.001). Patients with early TPE initiation after ECMO cannulation (<1 day) showed more improvement in MOFI and platelet counts than patients with late TPE initiation (p < 0.001 for each). Overall survival to hospital discharge was 53.7%. The within-groups hospital survival was 73.3% for patients with heart failure, 34.8% for patients with congenital heart disease, and 100% for those with other cardiac disease (p = 0.016). CONCLUSION: In children with critical cardiac disease and clinical diagnosis of TAMOF necessitating ECMO for hemodynamic support, concurrent TPE may be associated with an improvement in organ failure and platelet count, particularly when started early. Further studies are warranted to establish the most effective use of TPE and its effect on survival in this population.

Patient Outcomes of an International Telepediatric Cardiac Critical Care Program.

BACKGROUND: An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program. MATERIALS AND METHODS: A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS). RESULTS: Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min. CONCLUSIONS: An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.

International telemedicine in pediatric cardiac critical care: a multicenter experience.

OBJECTIVE: To describe our multicenter experience in telemedicine-assisted pediatric cardiac critical care (PCCC) with four hospitals in Latin America from July 2011 to June 2013. MATERIALS AND METHODS: This was a descriptive study based on telemedicine encounters related to quality of communication, assessed information, activities, and recommendations. Comparison among centers was performed. A postimplementation survey was conducted through a 5-point Likert scale questionnaire investigating acceptance among professionals involved with the telemedicine service through the assessment of general satisfaction, perception about the work system, usefulness, and impact on medical practice. RESULTS: One thousand forty consultations were conducted for 476 patients. Postoperatively, patients were distributed into Risk Adjustment Classification for Congenital Heart Surgery (RACHS-1) categories as follows: 2%, 26%, 36%, 26%, and 10% in categories 1, 2, 3, 4, and 6, respectively. A real-time intervention took place in 23% of encounters. Of the 2,173 recommendations given, 70 were related to extracorporeal membrane oxygenation management. There was a different RACHS-1 distribution and encounter characteristics among centers. From a total of 51 surveys sent, 27 responses were received, and among responders, overall satisfaction was very high (4.27 ± 0.18), as well as work system quality (4.4 ± 0.37). Telemedicine was considered useful in the cardiac intensive care unit (3.86 ± 0.60), for patient outcomes (3.8 ± 0.51), and for education (3.7 ± 0.71). There was a difference in overall satisfaction, perception about telemedicine usefulness in education, and impact on medical practice among centers. CONCLUSIONS: An international, multicenter telemedicine program in PCCC is technologically and logistically feasible. Prospective interventions in our international multicenter telemedicine program should consider differences in staff composition, perception of needs, and patient population among centers.

[Aortic arch advancement surgery as treatment for aortic coarctation with hypoplastic aortic arch in children]. / Avance de arco aórtico en el manejo de la coartación de aorta con hipoplasia del arco aórtico en niños.

INTRODUCTION: Treatment of aortic coarctation with hypoplastic aortic arch is still a surgical challenge. The aortic arch advancement surgery has shown less re-coarctation frequency. OBJECTIVE: To determine the re-coarctation frequency in patients who underwent aortic arch advancement technique for aortic coarctation with hypoplastic aortic arch and analyze the results. MATERIAL AND METHODS: Retrospective and observational study of 38 patients who underwent aortic arch advancement in a third level Institution from 2002 to 2010. RESULTS: Twenty four males and 14 females all with aortic arch Z index diameter of < or = -2 were found. The median age was 2.6 months and the median weight was 3.8 kg. Twelve patients (31.5%) did not show post operative complications. Eighteen (47%) had only one complication; one patient (2.6%) had 2 complications and 2 (5.2%) had 3 complications. After a follow up of 3.7 years the frequency of re-coarctation was O%. DISCUSSION: With the previously mentioned technique the recoarctation frequency on medium and long term basis was 0%. From the anatomical and functional point of view, we believe this technique offers the best possible results.

Películas infantiles como alternativa a la sedación en el estudio ecocardiográfico de pacientes pediátricos

Introducción. La realización del ecocardiograma se dificulta si el niño no coopera, por lo que es necesario sedarlo. Para evitar los posibles efectos adversos de la sedación se ha propuesto utilizar la proyección de películas infantiles durante el estudio. Material y métodos. Se formaron 2 grupos de pacientes no cooperadores entre 1 y 3 años de edad de manera aleatoria: uno sometido a sedación (13 niños) y otro al que se proyectó una película infantil (15 niños). En ambos grupos se evaluaron escalas semicuantitativas de cooperación, calidad de imagen y el tiempo de realización del estudio. Resultados. No se encontró diferencia estadísticamente significativa entre ambos grupos en cuanto a las escalas de cooperación y calidad de imagen, así como en el tiempo de realización del estudio. Conclusiones. Este método evita la exposición a los riesgos de la sedación, obteniendo cooperación e información similares, y pudiera disminuir los recursos necesarios para la realización del estudio.

Introduction. It is often difficult to perform echocardiograms in small children because of lack of cooperation, hence the need for sedation. In order to avoid the possible adverse effects of sedation, the projection of age-appropriate films during the study has been proposed as an alternative. Material and methods. Pediatric non-cooperative patients, ages between 1 and 3 years old with an indication for elective echocardiography were randomly assigned to either 1 of 2 groups: the first one (13 patients) with intranasal midazolam sedation (300 mg/kg), and the other group (15 patients) with video-projection of movies. Cooperation and image quality scores differences were evaluated (Mann-Whitney), as well as the mean study performance time between the 2 groups. Results. Cooperation and image quality scores were similar between the 2 groups. There was a trend toward a shorter mean study performance time in the video group, not reaching statistical significance. Conclusions. Projection of age-appropriate movies during echocardiographic studies in pediatric non-cooperative patients is a good alternative to sedation, avoiding related risks and resource expenditure with similar cooperation and echocardiographic information.

Enfermedad adenomatoidea quística pulmonar con hipertensión arterial pulmonar (uso de ventilación de alta frecuencia oscilatoria, óxido nítrico inhalado y cirugía) / Cyst adenomatoid malformation of the lung with pulmonary arterial hypertension (use of oscillatory high frequency ventilation, nitric oxide and surgery

Objetivo. Informar de un caso de enfermedad adenomatoidea quística pulmonar diagnosticada in utero que cursó con insuficiencia respiratoria e hipertensión pulmonar severa, no logrando corregirla con neumonectomía, ventilación de alta frecuencia oscilatoria y óxido nítrico inhalado. Caso clínico. Masculino a término eutrófico complicado con polihidramnios e imágenes quísticas en la cavidad torácica izquierda a las 26 semanas de gestación. Al nacimiento y por la posibilidad de hernia diafragmática congénita se orointuba para ventilación asistida. La radiología simple y contrastada diagnosticó enfermedad adenomatoidea quística del pulmón. Se usó inicialmente la ventilación mecánica convencional sin oxigenarlo ni ventilarlo. El ecocardiograma, oximetrías pre y posductales mostraron hipertensión pulmonar severa y cortocircuito de derecha a izquierda por el conducto arterioso. La ventilación de alta frecuencia oscilatoria fue capaz de corregir la insuficiencia respiratoria. Posteriormente se neumonectomiza, recae en hipoxemia e hipercapnea. Se aplica óxido nítrico inhalado. Las alteraciones no se corrigen y fallece (17 horas de vida). Discusión. La malformación adenomatoidea quística pulmonar acompañada de hipertensión pulmonar severa es rara. El análisis del caso considera usar de inicio la ventilación de alta frecuencia oscilatoria y óxido nítrico inhalado y estabilizado el paciente, efectuar resección quirúrgica del pulmón, como en la hernia diafragmática congénita, en donde el estrés quirúrgico incrementa la hipertensión pulmonar y de no lograrlo, considerar oxigenación extracorpórea. Conclusiones. 1) La enfermedad adenomatoidea quística pulmonar puede cursar con hipertensión pulmonar. 2) Estos pacientes deben estabilizarse con ventilación asistida y óxido nítrico inhalado previo a la resección quirúrgica, de no lograrlo, considerar el uso de la oxigenación extracorpórea

Terapia intensiva pediátrica: lujo o necesidad. Trece años de experiencia en el Hospital Central Militar / Intensive therapy in pediatrics: an actual necessity or a mare luxory modern convenience. Thirteen years of experience at the Militar Central Hospital

Se analizaron los datos de 2724 pacientes registrados en los archivos de la unidad de terapia intensiva pediátrica del Hospital Central Militar, desde su fundación, el 1 de septiembre de 1978 hasta el 31 de diciembre de 1990. Para su estudio se agruparon los datos en cuatro lapsos: de 1978 a 1981; de 1982 a 1985; de 1986 a 1989 y 1990. La mortalidad en los neonatos no ha variado en los lapsos estudiados (x=43.25 por ciento), pero el índice de gravedad evaluado por el número de procedimientos invasores ha aumentado significativamente del primero al último lapso. En niños mayores se observó una disminución significativa de la mortalidad, de 30.6 por ciento en el primer lapso a 17.4 por ciento en el último. La ventilación mecánica aumentó significativamente a través del tiempo hasta 81.6 por ciento disminuyendo asimismo la mortalidad a 45.9 por ciento en los neonatos sujetos al procedimiento; en los mayores la mortalidad también ha disminuido significativamente a 44.4 por ciento. Los pacientes contagiosos y reversos han aumentado de manera importante a través del tiempo. No es posible comparar nuestros resultados con los de otros autores debido a que nuestro estudio está basado en una clasificación por intervenciones, siendo sólo útil para comparar nuestro propio universo. Se propone utilizar escalas de criterios fisiológicos para poder hacer comparaciones con otras unidades de terapia intensiva pediátrica nacionales y extranjeras.

Diagnóstico de comunicación interventricular por resonancia magnética / Diagnosis by magnetic resonance imaging (MRI)

Las técnicas no invasivas han cobrado cada vez mayor importancia para la valoración pre y posoperatoria de las cardiopatías congénitas. La resonancia magnética ofrece un potencial enorme de aplicación para el estudio de las mismas, debido a su capacidad para el análisis anatómico y fisiológico del corazón. Se informa de un caso de comunicación interventricular en el cual la resonancia magnética fue útil para la evaluación preoperatoria, y se le propone como parte integral de la valoración de niños y adultos con cardiopatía congénita.